Spinal and spinal cord

1. Spinal and spinal cord 外傷科主治醫師 Hsinglin

2. Low back pain and radiculopathy • Imaging studies and further testing not helpful the first 4 weeks • Relief of discomfort with meds and spinal manipulation • Bed rest beyond 4 days may be more harmful • 89-90% low back pain improve within 1 month

3. 80% sciatica eventually recover • 1% have nerve-root symptoms • 1-3% have lumber disc herniation • 85% no specific diagnosis made

4. definitions/classifications • Radiculopathy : dysfunction of nerve root ( pain, sensory disturbances, weakness) • Mechanical low back pain : strain of paraspinal muscles, ligament, irritation of facet joints

5. Initial assessment of patient • History : • age, weight loss, cancer or infection, used of drug, during of S/S, trauma, cauda equina syndrome, work status • PE : • fever, vertebral tenderness, limited range of spinal cord Dorsiflexation of ankle and big toe – L5, 4 Achilles reflex – S1 Light touch SLR text

6. Further evaluation of patients • EMG : neuropathy, myopathy, myelopathy, unreliable < 3-4 weeks • SEPs (somatosensory evoked potential): spinal stenosis, or spinal myelopathy • NCVs (nerve conduction velocity): entrapment neuropathies that mimic radiculopathy

7. LS X-ray recommendation • age >70yrs, or <20 yrs • systemically ill patients • temp. 38°C • History of maligancy • Recent infection • Cauda equina syndrome • Heavy alcohol or drug abusers • DM

8. Immunosupressed patients (steroid) • Recent trauma • Recent urinary tract or spinal surgery • Unrelenting pain at rest • Persistent pain more than 4 weeks • Unexplained weight loss

9. Treatment • Conservative treatment : • 1.activity modification: • Bed rest : no more than 4 days • Activity modification : heavy lifting, total body vibration, asymmetric postures, sustained for long periods • Exercise : walking, bicycling, or swimming

10. 2.analgesics : • Panadol and NSAIDs • Opioids • 3.muscle relaxants : • no effect • 4.education: • condition will subside • 5.spinal manipulation therapy: • acute low back pain without radiculopathy in 1st month, not used in severe or progressive neurologic deficit

11. Epidural injection: no change in the need for surgery, short-term relief of radicular pain when control on oral medications is inadequate or not surgical candidates.

12. Cauda equina syndrome • Midline, most common at L4-5 • 1.sphincter retension : • A. urinary retension • B. Urinary and fecal incontinence • C. Anal sphincter tone • 2.saddle anesthesia • 3.significant motor weakness • 4.Low back pain and sciatica • 5.Bilateral absence of achilles reflex • 6.Sexual dysfunction

13. Surgical treatment • Patients with <4-8 weeks • A: urgent treatment (e.g. cauda equina syndrome, progressive neurologic deficit) • B: inability to control pain with medicine • Patient with >4-8 weeks • Severe and disabling and not improvement with time, correlated with findings on PH and PE.

14. Type of surgery • Lumbar spinal fusion : fracture/dislocation or instability resulting from tumor or infection • Instrumentation as an adjunct to fusion : increasing the fusion rate • Pedicle screw-rod fixation : utilize following laminectomy, shorter length of fixation segment, rigid fixation of all 3 columns

15. Posterior lumber interbody fusion : bilateral laminectomy and aggressive discetomy followed by bone grafts

16. Intervertebral disc herniation • Lumbar disc herniation • Posteriorly, one side, compressing a nerve root, severe radicular pain • Characteristics findings : • Symptoms start with back pain, days after weeks yeilds radicular pain with reduction of back pain • Pain relief upon flexing the knee and thigh • Position change

17. Bladder symptoms : difficulty voiding, straining, or urine retention • Exacerbation with coughing, sneezing, straining at the stool • Radiculopathy : • A.pain radiating down LE • B.motor weakness • C.dermatomal sensory changes • D.reflex changes

18. Straight leg raising test : <60, L5 and S1

19. Spondylosis : no-specific degenerative process of the spine • Spondylolisthesis : anterior subluxation of one vertebral body on another • Grade 1-4 • Spondylolysis : alternative term for isthmic spondylolisthesis

20. Spinal stenosis • Narrowing of the AP dimension of spinal canal • In the lumbar region : neurogenic claudication • In the cervical region : myelopathy and ataxia • In the spinal region : rare

21. Spinal trauma • Uncommon in children • The fatality rate is higher with pediatric spinal injuries than with adults (opposite to the situation with head injury)

22. Complete lesion : • no preservation of any motor or sensory function more than 3 segments below the level of the injury • Persistence of complete spinal cord injury beyond 24 hours : no distal function will recover

23. Incomplete lesion: • Any residual motor or sensory function more than 3 segments below the level of the injury. • Signs of incomplete lesion : • Sensation or voluntary movement in the Legs • Sacral sparing Central cord syndrome Bown-Sequard syndrome Anterior and posterior cord syndrome

24. Spinal shock • A. interruption of sympathetics • 1. Loss of vascular tone • 2. Leaves parasympathetics causing bradycardia • B. Loss of muscle tone result venous pooling • C. True hypovolemia

25. Initial management of spinal cord injury • Cause of death : aspiration and shock • SCI : • Significant trauma • Loss of consciousness • Minor trauma with spinal pain • Associated findings suggestive of SCI : • Abdominal breathing • priapism

26. Management in the hospital • 1. Immobilization • Hypotension: maintain SBP>90mmhg • Dopamine, careful hydration, atropine for bradycardia associated with hypotension • Oxygenation • NG tube decompression • Indwelling foley • Temperature regulation

27. Electrolytes • Medical management specific to spinal cord injury : • methylprednisolone : given with 8 hours of injury